Pericapsular Nerve Group (PENG) Block for Hip Fracture

REGIONAL ANESTHESIA AND ACUTE PAIN

BRIEF T ECHNICAL R EPORT EPORT

Pericapsular Nerve Group (PENG) Block for Hip Fracture Laura Laur a Girón-Ar Girón-Arango ango,, MD,*† Philip Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Med),*† Ki Jinn Chin, MBBS, MMed, FANZCA, FAMS, FAMS, FRCPC,*† Richard Richar d Brull, MD, FRCPC,* and Anahi Perlas, Perlas, MD, FRCPC*†

Abstract: Fasc Fascia ia iliaca block or femoral femoral nerve block is used frequen frequently tly in

D o w n l o a d e d f r o m h t t p : / / j o u r n a l s . l w w . c o m / r a p m b y B h D M f 5 e P H K b H 4 T T I m q e n V I i u K V F 7 q T x s l 3 p P M O H R a q p T p 8 J H X u h i u j A v I S w 6 f k T c o n 0 7 / 3 1 / 2 0 1 8

hip frac fracturepatientsbecaus turepatientsbecausee of thei theirr opio opioid-s id-spari paring ng eff effects ects and red reductio uction n in opioid-related adverse effects. A recent anatomical study on hip innervation tio n led to the ide ident ntific ificati ation on of rel relev evant ant lan landma dmarksto rksto tar target get th thee hip art artic icula ular r branchess of femoral nerve and accessory obturator branche obturator nerve. Using this information, we developed a nove novell ultrasou ultrasound-guided nd-guided approach for blockade of these articular branches to the hip, the PENG (PEricapsular Nerve Group) block. In this report, we describe the technique and its applicatio application n in 5 consecutive patients. ( Reg Anesth Pain Med 2018;43: 2018;43: 00 – 00) 00)

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ip fracture is a common orthopedic emergency in the elderly, and it is associated with significant morbidity and mortality. 1 Surgical Sur gical reduction reduction and f ixatio ixation n are the definiti definitive ve treatment in 2 most patients. Effective perioperative analgesia that minimizes the need for opioids and related adverse effects (such as delirium) is essential in this patient population. 3,4 Regional Regi onal analg analgesic esic techni techniques, ques, inclu including ding femor femoral al nerve (FN) block, bloc k, fascia iliaca block (FIB), (FIB), and 3-in-1 3-in-1 FN block block,, are popul popular ar analgesic analg esic strategies, strategies, due main mainly ly to their opio opioid-sp id-sparing aring effects effects and reduction in opioid-related adverse effects. 5 – 7 The effect size of analgesia from these blocks is only moderate, 8 and literature suggests that the obturator nerve (ON) is not covered. 9,10 The anterior hip capsule is innervated by the ON, accessory obturator nerve (AON), and FN as reported by previous anatomic 13 studies.11 – 13 The anterior capsule is the most richly innervated section of the joint, 14 suggesting these nerves should be the main target tar getss for hip ana analges lgesia. ia. A rece recent nt ana anatom tomica icall stud study y by Sho Short rt et al 15 confirmed the innervation of the anterior hip by these 3 main nerves, but also found that the AON and FN play a greater role in the anterior hip innervation than previously reported. 16 This study also identified the relevant landmarks for those articular branches. bran ches. The high articular articular branches branches from from FN and AON AON are consistently found between the anterior inferior iliac spine (AIIS) and the iliopubic eminence (IPE), whereas the ON is located close to the inferomedial acetabulum. Using this information, we developed an ultrasound-guided technique for blockade of these articular branches to the hip, the PENG (PEricapsular Nerve Group) block. bloc k. In this repor report, t, we descri describe be the techni technique que and its effec effectiv tivee ap plication plica tion in 5 patie patients nts with hip fractu fracture. re.

METHODS

Patients admit Patients admitted ted to the Toront oronto o Western Hospital Hospital with a fractured hip are assessed by the Acute Pain Service as part of a multidisc mult idisciplin iplinary ary care pathw pathway ay.. Patie Patients nts with signific significant ant pain, opioid use use,, or opi opioid oid-re -relat lated ed adv advers ersee eff effect ectss are of offer fered ed reg region ional al ana anallgesia as a comp component onent of a multi multimodal modal analgesic analgesic regimen. We We performed perf ormed the PENG bloc block k in 5 patien patients ts follo following wing a discus discussion sion of the potential risks and benefits. Written informed consent was obtained from all 5 patients for this report. Demographic information, types of hip fracture and subsequent surgery, and types of injectate in the regional block are noted in Table 1. Pain scores at rest and with a straight leg raise of the affected limb to 15 degrees were assessed before and 30 minutes after block performance. Before the procedure, all patients reported severe hip pain despite intravenous opioids (Fig. 1, A and B). In 4 of 5 cases, a single-injection block was perf pe rform ormed ed in wh which ich 20 mL of 0.25% 0.25% bu bupi piva vacai caine ne with with epi epinep nephr hrin inee 1:400 1:4 00,00 ,000 0 was used. In the remainin remaining g cas case, e, 20 mL of 0.5 0.5% % ropivaca ropi vacaine ine with epinep epinephrin hrinee 1:200, 1:200,000 000 plus dexam dexamethaso ethasone ne 4 mg was used. The regional block was performed with the patient in the su pine posit position. ion. A curvi curvilinea linearr low low-freq -frequenc uency y ultra ultrasound sound prob probee (2 – 5 MHz MHz)) was initiall initially y placed placed in a tra transv nsvers ersee plan planee over over the AII AIIS S and then then align aligned ed with the pubic pubic ramus ramus by rotati rotating ng the the probe probe coun coun-terclockwise approximately 45 degrees (Figs. 2, 3). In this view, the IPE, the iliopsoas muscle and tendon, the femoral artery, and pectineus pectin eus muscl musclee wer weree observ observed. ed. A 22-ga 22-gauge, uge, 80-m 80-mm m needl needlee was inserted from lateral to medial in an in-plane approach to place the tip in the muscu musculofasc lofascial ial plane betw between een the psoas tendon tendon anteriorly and the pubic ramus posteriorly. Following negative as piration, pirat ion, the local anesthetic solution solution was injected in 5-mL increments men ts whi while le obs observ erving ing for ade adequa quate te flui fluid d spr spread ead in thi thiss pla plane ne for for a total volume of 20 mL (Fig. 4). RESULTS

Thirty minutes after block placement, we evaluated all patients by asking them to flex at the hip and to perform a straight leg raise of the affected limb to 15 degrees. All patients were able to comply and reported significantly reduced pain scores com pared with baseline baseline (Fig. 1). In addit addition, ion, no quadriceps quadriceps weakness weakness was clinically evident in any of the patients. DISCUSSION

From the *Department of Anesthesia, Toronto Western Hospital; and †University Health Network, University of Toronto, Toronto, Ontario, Canada. Accepted for publication April 14, 2018. Address correspondence to: Philip W.H. Peng, MBBS, FRCPC, Founder (Pain Med), Department of Anesthesia, McL 2-405, TWH, 399 Bathurst Street, Toronto, Ontario, Canada M5T 2S8 (e‐mail: philip.peng@ [email protected] uhn.ca). ). A.P. has a rese research arch grant from Fis Fisher her and Pyke Pykel. l. P.W.H.P. has equi equipmen pmentt supp support ort from Fujifilm/Sonosite Canada. The other authors declare no conflict of interest. The authors have no sources of funding to declare for this article. Copyright © 2018 by American Society of Regional Anesthesia and Pain Medicine ISSN: 1098-7339 DOI: 10.1097/AAP.0000000000000847

Regional Anesthesia and Pain Medicine

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Regional analgesia techniques are commonly used for pain management in patients with hip fractures as they provide reasonablee ana abl analge lgesia sia wit with h an opi opioid oid-spa -sparin ring g eff effect ect and are rel relati ativel vely y saf safe. e. A recent Cochrane review on nerve blocks for hip fractures, which included FIB, FN block, and 3-in-1 FN block, demonstrated high-quality evidence supporting a reduction in dynamic pain within within 30 minutes of block placement. placement. The effect effect size in this review was −3.4 points on a scale from 0 to 10. 8 The cephalad spread of local anesthetic from both 3-in-1 and FIB has been examined with magnetic resonance imagining. The ON is consistently not covered. More importantly, the cephalad

Volume 43, Number Number 8, November 2018

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Girón-Arango et al

TABLE 1. Characteristics

Cases

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Volume 43, Number 8, November November 2018

of Patients

Sex

Age, y

ASA

Side

Hip Pathology

1

F

70

III

L

Intertrochanteric fracture

2

F

80

III

L

Subcapital fracture

Hip hemiarthroplasty

3

M

68

IV

R

Total hip arthrop arthroplasty lasty

4

M

62

II

L

Metastatic tumor in femoral head and acetabulum Intertrochanteric fracture

5

F

72

III

R

Subcapital fracture

Total hip arthroplasty

Type and Volume of Local Anesthetic

Type of Surgery

DHS f ixation

DHS f ixation

Bupivacaine 0.25% with epinephrine 1:400,000 20 mL Bupivacaine 0.25% with epinephrine 1:400,000 20 mL Bupivaca Bupi vacaine ine 0.25% with epine epinephrin phrinee 1:400,000 20 mL Bupivacaine 0.25% with epinephrine 1:400,000 20 mL Ropivacaine 0.5% with epinephrine 1:200,000 20 mL and 4 mg of dexamethasone

ASA indicates American Society of Anesthesiologists; DHS, dynamic hip screw; F, female; L, left; M, male; R, right.

spread is unlikely to extend beyond the L5 level. 9,10 A recent anatom at omic ic stu study dy sh show owed ed th that at th thee art artic icul ular ar br bran anch ches es fr from om th thee FN to th thee hip joint enter the iliacus muscle at the L4 – L5 L5 level and course deep to the psoas muscle and tendon between the AIIS and IPE beforee innerv befor innervating ating the hip capsu capsule le (Fig (Fig.. 5). The AO AON N course coursess deep to the medial aspect of psoas muscle around the L5 level. It then

courses deep to the psoas around IPE to enter the anteromedial joint capsul joint capsulee (Fig (Fig.. 5).17 Therefore, neither the 3-in-1 nor the FIB is lik likely ely to con consis sisten tentl tly y blo block ck the arti articul cular ar bra branch nches es fro from m the AON and FN. In contrast, the targets of the regional block described in our case series were the articular branches of AON and FN between

A, Rest pain score before and 30 minutes minutes after the block. The postblock postblock pain score for patients 1, 2, 4, and 5 were 0. Reproduced Reproduced with permission from Philip Peng Educational Series. B, Dynamic pain score before and 30 minutes after the block. Reproduced with permission from Philip Peng Educational Series. FIGURE FIG URE 1.

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PENG Block for Hip Fracture

FIGURE 2. Figure showing the position of the hip, orientation of the ultrasound probe, and needle insertion. Reproduced with permission from Philip Philip Peng Educational Educational Series. Series.

The area revealed by ultrasound in Fig. 2 is demonstrated demonstrated in this figure. Line arrow: AIIS, bloc blockk arrow: IPE. Reproduced Reproduced with permission from Philip Peng Educational Series. FIGURE 3.

The corresponding sonogram from Fig. 3. The figure on the left shows the needle position. The needle is outlined by the arrows. The figure on the right shows the local anesthetic anesthetic spread following following injection. injection. FA indic indicates ates femoral artery; LA, local anesthetic; anesthetic; PE, pectineus pectineus muscle. *Psoas tendon. Reproduced with permission from Philip Peng Educational Series. FIGURE FIG URE 4.

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Anatomy of the articular branches of FN and a ccessory FNs in cadaveric dissection. The figure on the l eft side shows the articular branches branch es of FN (hi (highl ghligh ighted ted in gre green) en) cou coursi rsing ng betw between een AII AIIS S andIPE tow toward ard the hipcapsu hipcapsule. le. The fem femoralhead oralhead is out outlin lined ed by the dot dotted ted lin line. e. The figure on the right side shows the course of the AON (high (highlight lighted ed in blue) passing passing over the IPE. The areas of dissection are shown in the insert on the left upper corners. Reproduced with permission from Philip Peng Educational Series. FIGURE 5.

AIIS and IPE. We are not able to comment on whether the local anesthetic would spread medially enough to reach the plane between the pectineus and obturator externus muscles (subpectineal plane [SPP [SPP]) ]) wher wheree the articu articular lar branch branches es of ON can be foun found. d. The SPP, wh which ich is ide identifi ntifiab able le by ult ultras rasoun ound d, has bee been n rec recentl ently y described scr ibed by Nielsen Nielsen et al.18 as a target point for ON and its articular articular branches. branc hes. Giv Given en the prox proximit imity y of the SPP, it is conce conceiv ivable able that the local loc al anes anesthe thetic tic injected injected in our cases ma may y ha have ve spr spread ead to thi thiss plane.. However plane However,, dye inject injection ion studi studies es wou would ld be needed to confirm this possibility possibility.. The median median reduc reduction tion of pain in in our case series was 7 points, points, showing a larger decrease than the one previously reported for other regi regional onal techn techniques iques in hip fractu fracture re patie patients. nts. Inter Interesting estingly ly,, the patients in our case report presented with different hip pathologies (intertrochanteric fracture, subcapital fracture, and femoral head metastases), and all 5 of them reported significant dynamic pain relief. In addit addition, ion, given that our techni technique que targets onl only y the sensory branches, there is a potential motor-sparing effect com pared with both the FIB and the FN block block.. This is only a small case series, and there are limitations inherent to this type of publication, such as lack of ability to generalize, publication bias, danger of overinterpretation, and retrospective design. 19 However, there are merits of this type of publication such as the detection of novelties and generation of hypoth hypotheses. eses. Altho Although ugh the FIB and FN have have been sho shown wn to be effective in providing analgesia, there is room to improve the effect size of analgesia as discussed before. This consecutive case series demonstrated a very impressive effect of the new block on the dynamic pain score. With the better understanding of the anatomy for hip innervation 15 and the planes where the nerves to the hip innervation run, 15,18 this case series may help researchers to consider a new approach of nerve block for patients with hip fracture. Larger studies need to be conducted to compare the efficacy of this new technique with that of the more established regional regional techniques for hip analgesia, as well

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as anatomic studies to confirm the spread of local anesthetics and the nerves targeted.

REFERENCES

1. Brauer CA, Coca-Perraillon Coca-Perraillon M, Cutler DM, Rosen AB. Incidence Incidence and mortality of hip fractures in the United States. JAMA States. JAMA.. 2009;302: 1573 – 1579. 1579. 2. Neuman MD, Fleisher Fleisher LA, Even-Shoshan O, Mi L, Silber JH. Nonoperative Nonoperati ve care for hip fracture in the elderly: the influence of r ace, income, and comorbiditi comorbidities. es. Med Med Care. Care. 2 010;48:31 010;48:314 4 – 320. 320. 3. Morrison Morrison RS, Magaziner Magaziner J, Gilbert Gilbert M, et al. Relationsh Relationship ip betw between een pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci. Sci. 2003;58:76 – 81. 81. 4. Morrison RS, Magaziner J, J, McLaughlin MA, et al. The impact of post-operative post-operati ve pain on outcomes following hip fracture. Pain. Pain. 2003;103: 303 – 311. 311. 5. Foss NB, Kristensen Kristensen BB, Bundgaard M, et al. Fascia iliaca compartment compartment blockade for acute pain control i n hip fracture patients: a randomized randomized,, placebo-controlled placebo-contr olled trial. Anesthesiolo Anesthesiology gy.. 2007;106:773 – 778. 778. Haines L, Dickman E, Ayvazyan S, Pearl M, Wu S, Rosenblum D, et al. Ultrasound-guided fascia iliaca compartment block for hip fractures in the emergency emergenc y department. department. J J Emerg Med. Med. 2012;43:692 – 697. 697. 6. Unneb Unneby y A, Sv Svens enssonO, sonO, Gus Gustaf tafsonY,Olofs sonY,OlofssonB. sonB. Femo emoralnerveblockin ralnerveblockin a representative sample of elderly people with hip fracture: a randomised controlled trial. Injury trial. Injury.. 2017;48:1542 – 1549. 1549. 7. Beaudoin FL, Haran JP, JP, Liebmann O. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial. Acad trial. Acad Emerg Med . 2013;20: 584 – 591. 591. 8. Guay J, J, Parker MJ, Griffiths R, Kopp S. Peripheral nerve blocks blocks for hip fractures. Cochrane fractures. Cochrane Database Syst Rev. Rev. 2017;5:CD001 2017;5:CD001159. 159.

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9. Marhof Marhofer er P, Nas Nasel el C, Sit Sitzw zwoh ohll C, Kap KapralS. ralS. Mag Magnet netic ic res resona onanceimag nceimagingof ingof the distribution of local anesthetic during the three-in-one block. Anesth block. Anesth Analg . 2000;90:11 2000;90:119 9 – 124. 124. 10. Swenson JD, JD, Davis JJ, Stream JO, Crim JR, Burks RT, RT, Greis PE. Local anesthetic injection deep to the fascia iliaca at the level of the inguinal ligament: the pattern of distribution and effects on the obturator nerve. J Clin Anesth Anesth.. 2015;27:652 – 657. 657. 11. Wertheimer LG. The sensory nerves of hip joint. joint. J J Bone Joint Surg Am. Am. 1952;34 – A:477 A:477 – 487. 487. 12. Birnbaum Birnbaum K, Presc Prescher her A, Hess Hessler ler S, Hell Heller er KD. The sensory sensory inne innervat rvation ion of the hip joint — an an anatomical study. Surg study. Surg Radiol Anat . 1997;19:37 1997;19:371 1 – 375. 375. 13. Gardner E. The innervation innervation of the hip joint. joint. Anat Anat Rec. Rec. 1948;101:3 1948;101:353 53 – 371. 371. 14. Gerhardt M, Johnson K, Atkinson Atkinson R, et al. Characterisation Characterisation and classification of the neural anatomy in the human hip joint. Hip joint. Hip Int . 2012; 22:75 – 81. 81.

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PENG Block for Hip Fracture

15. Short AJ, Barnett JJG, JJG, Gofeld M, et al. Anatomic study of innervation innervation of the anterior hip capsule: implication for image-guided intervention. Reg Anesth Pai Pain n Med . 2018;43:18 2018;43:186 6 – 192. 192. 16. Bhatia A, H oydon oydonckx ckx Y, Peng P, P, Cohen SP SP.. Radiofrequency procedures to relieve chronic hip pain. An evidence-based narrative review. Reg review. Reg Anesth Pain Pai n Med . 2018;43:72 – 83. 83. 17. Archana BJ, Nagaraj DN, Pradeep P, P, Lakshmi Prabha S. Anatoical variations of accessory obturator nerve: a cadaveric study with proposed clinical implications implications.. Int J Anat Res. Res. 2016;4:2158 – 2161. 2161. 18. Nielsen TD, Moriggl B, Søballe K, Kolsen-Petersen Kolsen-Petersen JA, Børglum J, Bendtsen Bend tsen TF TF.. A cada cadaveri vericc stud study y of ultra ultrasoun sound-gu d-guided ided subp subpectin ectineal eal inje injectat ctatee spread spre ad aroun around d the obtu obturator rator nerv nervee and its hip artic articular ular bran branches. ches. Reg Reg Anesth Pain Pai n Med . 2017;42:35 2017;42:357 7 – 361. 361. 19. Nissen T, T, Wynn R. The clinical case report: a review of its merits and limitations. BMC Res Notes. Notes. 2014;7:264 2014;7:264..

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Pericapsular Nerve Group (PENG) Block for Hip Fracture

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